Customer Service Forms

The following forms and guides will help you administer your company's RBC Insurance group life, health or dental insurance policy.

Basic AD&D Insurance Monthly Premium Statement 
On a monthly basis, the plan administrator will need to complete a statement for self-administered plans detailing the activity on the group.
Form Number: 20101

Beneficiary Designation Card 
Employees purchasing life insurance are required to provide RBC Insurance with a beneficiary designation card to keep on file with the insurance plan. This is only necessary if you have not completed an Enrollment Card.
Form Number: 13049

Calculating an Employee's Monthly LTD Premium Amount 
Follow the instructions on this worksheet to calculate an employee's monthly volume and premium for long term disability insurance with a flat percentage.
Form Number: 13010

Calculating an Employee's Monthly LTD Split Premium Amount 
Follow the instructions on this worksheet to calculate an employee's monthly split volume and premium for long term disability insurance.
Form Number: 13012

Confirmation of Appointment of Third Party Administrator (TPA) 
As a policyholder, if you are appointing a TPA you must fill out this form with the TPA's name, policy number, and other relevant information.
Form Number: 13033B

Election of Portability Coverage - Voluntary Group Term Life Insurance 
If an employee has recently been terminated, they may be eligible to apply for conversion and become insured under the Group Voluntary Life Portability Policy. Learn about this benefit and how to apply.
Form Number: 13094

Employee Data Listing 
A grid that plan administrators can use to submit employee information at time of issue or renewal
Form Number: 13082

Evidence of Insurability Form 
Both the employee and the plan administrator must fill out this approval form for reasons specified within the insurance contract(s).
Form Number: 13074

Group Accident Insurance Conversion Notice ($100,000) 
Employees complete this application to exercise their Conversion Privilege under the Group AD&D Insurance Policy. It provides an opportunity for those persons leaving the Group, who are under the age of 70 years and a resident of Canada, to convert to an individual accident insurance policy.
Form Number: 73531

Group Accident Insurance Conversion Notice ($200,000) 
Employees complete this application to exercise their Conversion Privilege under the Group AD&D Insurance Policy. It provides an opportunity for those persons leaving the Group, who are under the age of 70 years and a resident of Canada, to convert to an individual accident insurance policy.
Form Number: 73532

Group Enrollment Card 
To enrol in group insurance, the employee and employer must fill out this card and return it to RBC Insurance.
Form Number: 13006

Group LTD Conversion Facts 
If your plan has a conversion option and an employee who has been covered for long term disability benefits under a group long term disability plan for at least 12 months, has recently terminated employment, that employee may be eligible to apply for conversion and become insured under the Group LTD Conversion Policy. Learn about its benefits and how to apply.
Form Number: 13079-1

Group Request for Change 
Both the employer and the employee must complete this form if the employee's name has changed, they wish to change their beneficiary information, or the number of dependents has changed. If adding a dependent through marriage or birth, we must receive this form within 31 days of the event.
Form Number: 13017

iServices Orientation Package 
This iServices User Guide will help you understand how to administer the benefit plan your Company purchased from RBC Insurance. This tool will help you manage the details and procedures you need to be aware of to successfully administer your benefits program.
Form Number: 82694

Life Conversion Application 
If an employee has recently been terminated or their life coverage was reduced, they may be eligible to apply for conversion and become insured under the Group Life Conversion Policy. Learn about its benefits and how to apply.
Form Number: 13086

Maternity/Parental Leave of Absence - Opting Out of Coverage 
Both the employer and employee must complete this form if the employee elects to discontinue his/her coverage's offered under their employer's mandatory plan while on Maternity/Parental leave of absence.
Form Number: 84684GSI

Monthly Group Premium Statement 
On a monthly basis, the plan administrator will need to complete a statement for self-administered plans detailing the activity on the group.
Form Number: 13092

Plan Administrator Guide to the Guarantee Standard Issue^® (GSI^®) 
Download this guide if your company has purchased GSI and, as the plan administrator, you wish to learn more about the administration of the plan.
Form Number: 83556

Plan Administrator's Guide Integrated 
Download this guide if your company has purchased a combination of group insurance and GSI and, as the plan administrator, you wish to learn more about the administration of the plan.
Form Number: 83588

Plan Administrator's Guide List Bill 
Download this guide if your company has purchased Group Insurance and, as the plan administrator, you wish to learn more about the administration of your list billed plan.
Form Number: 83572

Plan Administrator's Guide Self-Administered 
Download this guide if your company has purchased group insurance and, as the plan administrator, you wish to learn more about the administration of your self-administered plan.
Form Number: 83592

Plan Administration Made Easy: Key Points 
A list of key points and key contact numbers for plan administrators when enrolling employees or making member changes.
Form Number: 83617

Refusal of Coverage Form 
Both the employer and employee must complete this form if the employee does not wish to enrol in short and/or long term disability coverage offered under their employer's non-mandatory plan.
Form Number: 13026

Request for Group Insurance Supplies 
As plan administrator, complete and forward this form to your local RBC Insurance^® regional office to order application forms for group insurance, You'll need to know the application form numbers and quantities needed.
Form Number: 13008

Social Insurance Number Authorization Card 
If the employer chooses to use social insurance numbers for identification purposes, employees must provide us with authorization to use their social insurance number and keep it on file as part of the insurance plan.
Form Number: 13066

Status Change Form 
Employers must complete this form to report a change in status of an employee. Changes include termination, salary increase/decrease, insurance class, and account number/billing division.
Form Number: 13015B

Trustee Designation Card 
Employees must fill out and sign this card in order to appoint a trustee for a minor beneficiary.
Form Number: 13090B

Voluntary Accident Insurance Enrollment Form 
To enrol in group voluntary AD&D insurance, the employee and employer must complete this card and return it to RBC Insurance.
Form Number: 20103

Voluntary AD&D Insurance Monthly Premium Statement 
On a monthly basis, the plan administrator will need to complete a statement for self-administered plans detailing the activity on the group.
Form Number: 20105

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